Endoscopic management of pancreatic necrosis: state-of-the-art and emerging innovations

INTRODUCTION: Pancreatic necrosis is one of the serious complications of acute pancreatitis and is associated with substantial morbidity, prolonged hospitalization, and, when infected, considerable mortality. Over the past two decades, the therapeutic paradigm has evolved from early open surgical necrosectomy toward delayed, minimally invasive and increasingly endoscopic interventions. AREAS COVERED: This narrative review summarizes the contemporary evidence supporting endoscopic management of pancreatic necrosis, examines unresolved controversies regarding timing, drainage devices, and necrosectomy, and discusses emerging technologies that may define the future of minimally invasive management of pancreatic necrosis. The indications, timing and technical principles of direct endoscopic necrosectomy are reviewed, including the emerging evidence supporting upfront necrosectomy in selected patients. Emerging technologies, including powered endoscopic debridement systems, novel large-caliber drainage stents, forward-viewing echoendoscopy, and potential applications of artificial intelligence and image-guided intervention, are also discussed. EXPERT OPINION: Endoscopic treatment for pancreatic necrosis is evolving from a rigid step-up paradigm toward individualized, anatomy-and physiology-guided intervention. Transluminal drainage remains the cornerstone of therapy, with subsequent necrosectomy determined by clinical response, residual solid necrotic burden, and collection characteristics. Upfront necrosectomy may be considered in carefully selected patients with mature, encapsulated infected necrosis and substantial solid debris, particularly when adequate resolution with drainage alone is unlikely; however, current evidence does not establish routine upfront necrosectomy as superior to a drainage-first or on-demand strategy. Future research should focus on phenotype-based treatment algorithms and long-term patient-centered outcomes.